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<!DOCTYPE html>
<html>
    <head>
        <title></title>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
    </head>
    <body>

    <tr>
        <td>&nbsp;</td><td><br>Loan Details</td></tr><tr><td  align="right">Status</td>
        <td class="data"><input type = 'text' Name ="field[0]" id ="field[0]"
                                                                                                               value="" size="5" maxlength="5" onblur="validate('field[0]', 'Status', '')"/></td>
    </tr>
    <tr>
        <td  align="right">Description</td>
        <td class="data"><input type = 'text' Name ="field[1]" id ="field[1]"
                                                                                                                                                              value="" size="45" maxlength="45" onblur="validate('field[1]', 'Description', '')"/></td></tr>
    <tr>
        <td  align="right">Details</td>
        <td class="data">
            <textarea Name ="field[2]" id ="field[2]"      value="" cols="80" rows="10" onblur="validate('field[2]', 'Details', '')"/></td></tr>
    <tr>
        <td  align="right">Next Action</td><td class="data"><input type = 'text' Name ="field[3]" id ="field[3]"
                                                                                                                                                            value="" size="5" maxlength="5" onblur="validate('field[3]', 'Next Action', '')"/></td></tr><tr><td  align="right">Next Act Days</td><td class="data"><input type = 'text' Name ="field[4]" id ="field[4]"
                                                                                                                                                                     value="" size="2" maxlength="2" onblur="validate('field[4]', 'Next Act Days', 'num=Y')"/></td></tr><tr>
        <td></td><td><br><input id="btnsubmit" name="btnsubmit" type="submit" value="Submit" onClick="return(valid(document.frmclaim.txttele));" />
        </td>
    </tr> 



</body>
</html>
